The effectiveness of mindfulness-based cognitive therapy for reducing rumination and improving mindfulness and self-compassion in patients with treatment-resistant depression

Aliakbar Foroughi Kheirollah Sadeghi AliAkbar Parvizifard Arash Parsa Moghadam Omran Davarinejad Vahid Farnia Ghazale Azar About the authors

Abstract

Introduction

Depression is one of the most important psychiatric disorders, and the rate of recurrence is high. The heavy cost burden of depression is probably due to treatment-resistant depression. The purpose of this study was to determine the effectiveness of mindfulness-based cognitive therapy (MBCT) in patients with treatment-resistant depression (TRD).

Method

The present study was a quasi-experimental study conducted with twenty-four patients with treatment-resistant depression. Participants were selected by purposive sampling and randomly assigned to two groups, an experimental group and a control group. The experimental group received MBCT and antidepressants, while the control group received antidepressants only. The Hamilton and Beck Depression Inventory, Self-Compassion Scale, Thought Rumination Scale, and Mindfulness Scale were administered. The treatment program was conducted in eight sessions; with a follow-up period of one month subsequent to treatment termination. Data were analyzed using descriptive statistics (mean and standard deviation) and inferential statistics (analysis of variance for repeated measures and Bonferroni’s post-hoc test).

Results

The results showed that MBCT significantly reduced depression and ruminative thinking in the experimental group and also improved mediators such as mindfulness and self-compassion. Patients maintained gains over the one month follow-up period (p < 0.01).

Conclusion

The present study provides additional evidence for the effectiveness of MBCT for TRD.

Mindfulness-based cognitive therapy; acceptance; rumination; self-compassion; depressive disorder; treatment resistant

Introduction

Depression is one of the most devastating of all psychiatric disorders. It is the leading cause of mental and physical problems, affecting more than 300 million people.11. World Health Organization. Depression [Internet]. 2018. [updated 22 Mar 2018]. https://www.who.int/news-room/fact-sheets/detail/depression
https://www.who.int/news-room/fact-sheet...
Additionally, depression is considered a serious threat to the health of the community and is associated with significant mortality, disability, and economic burden.22. Mayo R. Depression and social function in primary care: a two-phase exploratory study. Prim Care Community Psychiatr. 2006;11:37-45. Epidemiological studies have shown that the prevalence of this disorder is 27%.33. Wang J, Wu X, Lai W, Long E, Zhang X, Li W, et al. Prevalence of depression and depressive symptoms among outpatients: a systematic review and meta-analysis. BMJ Open. 2017;7:e017173. Studies show that the prevalence of clinical depression in Iran is higher than in other countries and that women are more likely to be depressed than men.44. McIntyre RS, Filteau MJ, Martin L, Patry S, Carvalho A, Cha DS, et al. Treatment-resistant depression: definitions, review of the evidence, and algorithmic approach. J Affect Disord. 2014;156:1-7. , 55. World Health Organization. The World Health Report 2001: Mental health: new understanding, new hope. Geneva: WHO; 2001.

Treatment-resistant depression (TRD) is an overriding public health problem.55. World Health Organization. The World Health Report 2001: Mental health: new understanding, new hope. Geneva: WHO; 2001. Different definitions and models of TRD have been proposed. An overall agreement is that the lack of response to two or more different antidepressant medications represents TRD.44. McIntyre RS, Filteau MJ, Martin L, Patry S, Carvalho A, Cha DS, et al. Treatment-resistant depression: definitions, review of the evidence, and algorithmic approach. J Affect Disord. 2014;156:1-7. In TRD, the patient considers depression to be a part of himself or part of his self-concept; which can lead to total hopelessness and helplessness.66. Johnston KM, Powell LC, Anderson IM, Szabo S, Cline S. The burden of treatment-resistant depression: a systematic review of the economic and quality of life literature. J Affect Disord. 2019;242:195-210. The high cost of depression may be due to TRD77. Ledari RB, Masjedi A, Bakhtyari M, Zarghami M, Nouri R, Hosseini H. A comparison between the effectiveness of acceptance and commitment treatment and behavioral activation treatment for depression on symptoms severity and rumination among patients with treatment-resistant depression. Iran J Psychiatry Behav Sci. 2018;12:e10742. and there are several explanations for this. First, TRD is common; if we consider the response to treatment as the criterion, 35% to 40% of the patients do not respond to treatment, and if we consider improvement as the criterion, 60 to 75 percent of patients do not improve.88. Gotlib IH, Hammen CL. Handbook of depression. New York: Guilford; 2008. Secondly, the duration and severity of depression are high. Thirdly, patients with TRD are more likely to exhibit both physical and mental signs and symptoms that lead to evident and persistent dysfunction and impose a heavy cost burden on health systems.88. Gotlib IH, Hammen CL. Handbook of depression. New York: Guilford; 2008. Therefore, a better understanding of the consequences of TRD is an important objective in the field of mental health.

Combinations of antidepressants are often used as a treatment strategy when initial antidepressants are not effective. Despite the popularity of this approach, the Food and Drug Administration has not approved any antidepressants as an effective and persistent method of combined treatment strategy for TRD.44. McIntyre RS, Filteau MJ, Martin L, Patry S, Carvalho A, Cha DS, et al. Treatment-resistant depression: definitions, review of the evidence, and algorithmic approach. J Affect Disord. 2014;156:1-7. Moreover, psychological interventions are more stable and longer lasting, because patients learn how to cope with their problems.99. Tsang AW. Mindfulness [book review]. East Asian Arch Psychiatry. 2018;28:33. Depression is a multidimensional disorder with biological, psychological, social, and spiritual components.1010. Segal ZV, Williams M, Teasdale J. Mindfulness-based cognitive therapy for depression. 2nd ed. New York: Guilford; 2018. Antidepressants only put emphasis on the biological aspects; therefore, antidepressants alone do not have sufficient effect for treatment of depression (especially TRD) and there is a high rate of relapse after patients stop taking antidepressants.1111. Crane R. Mindfulness-based cognitive therapy: distinctive features. 2nd ed. London: Routledge; 2017. Although cognitive behavioral therapy is an effective treatment for depression, relapse remains a significant problem. Over recent years, a new cognitive behavioral therapy approach has emerged, known as the third wave and mostly based on acceptance and mindfulness. These treatments, which began in the early 1990s, have incorporated behavioral and cognitive components into new elements such as dialectical philosophy, mindfulness, acceptance, and spirituality.1111. Crane R. Mindfulness-based cognitive therapy: distinctive features. 2nd ed. London: Routledge; 2017. Mindfulness-based cognitive therapy (MBCT) is one of these treatments, integrating training in mindfulness meditation with cognitive behavioral therapy. It is a relapse prevention intervention specifically for people who have a history of perennial major depressive disorder.1010. Segal ZV, Williams M, Teasdale J. Mindfulness-based cognitive therapy for depression. 2nd ed. New York: Guilford; 2018. MBCT includes four well-known mediators that can positively affect TRD: mindfulness, reduced depressive rumination, increased acceptance and self-compassion, and reduced avoidance.1010. Segal ZV, Williams M, Teasdale J. Mindfulness-based cognitive therapy for depression. 2nd ed. New York: Guilford; 2018. Mindfulness is referred to as non-judgmental awareness of present-moment current experience.1212. Kabat-Zinn J. Mindfulness-based interventions in context: past, present, and future. Clin Psychol Sci Pract. 2003;10:144-56. Kabat-Zinn defined mindfulness as a state of paying attention in a particular way which has three features: focusing purposefully and non-judgmentally on the present moment.1313. Kabat-Zinn J, Hanh TN. Full catastrophe living: using the wisdom of your body and mind to face stress, pain, and illness. 15th ed. New York: Delta Book; 2009.

The primary aim of this study is to determine the effect of MBCT on TRD and secondary objective include to determine the potential mediators of MBCT effects on TRD, including mindfulness, self-compassion, and rumination. Self-compassion is the main mediator of the effects of MBCT in preventing relapse of depression. Neff (2003b) defines self-compassion as consisting of three main components (each component has two aspects); self-kindness versus self-judgment, a sense of common humanity versus a feeling of isolation, and mindfulness versus over-identification with experience.1414. Neff K. Self-compassion: an alternative conceptualization of a healthy attitude toward oneself. Self Identity. 2003;2:85-101. Research has shown that self-compassion correlates with psychological well-being and serves as a protective factor against depression.1515. Leary MR, Tate EB, Adams CE, Batts Allen A, Hancock J. Self-compassion and reactions to unpleasant self-relevant events: the implications of treating oneself kindly. J Pers Soc Psychol. 2007;92:887-904. , 1616. Neff KD, Rude SS, Kirkpatrick KL. An examination of self-compassion in relation to positive psychological functioning and personality traits. J Res Pers. 2007;41:908-16. Increasing self-compassion in depressed patients and reducing avoidance of unpleasant situations can help to lessen overall emotional suffering.1717. Eisendrath S, Chartier M, McLane M. Adapting mindfulness-based cognitive therapy for treatment-resistant depression: a clinical case study. Cogn Behav Pract. 2011;18:362-70. , 1818. Hayes SC, Luoma JB, Bond FW, Masuda A, Lillis J. Acceptance and commitment therapy: model, processes and outcomes. Behav Res Ther. 2006;44:1-25.

Rumination is another main mediator of the effects of MBCT in preventing relapse of depression. Depressive rumination is the most likely factor mediating the relationship between self-compassion and depression.1919. Nolen-Hoeksema S, Wisco BE, Lyubomirsky S. Rethinking rumination. Perspect Psychol Sci. 2008;3:400-24. , 2020. Watkins ER. Constructive and unconstructive repetitive thought. Psychol Bull. 2008;134:163. Depressive rumination indicates a cognitive symptom of depression that is generally considered to be maladaptive. Diagnostically, rumination does not exist in all types of depression. In fact, it is a prolonged depressed mood and predicts maintenance of clinical depression.1919. Nolen-Hoeksema S, Wisco BE, Lyubomirsky S. Rethinking rumination. Perspect Psychol Sci. 2008;3:400-24. , 2020. Watkins ER. Constructive and unconstructive repetitive thought. Psychol Bull. 2008;134:163. Rumination is usually regarded as repetitive, involuntary, and distressing experiences with a negative cognitive focus on the symptoms and consequences of depression.2121. Brosschot JF, Gerin W, Thayer JF. The perseverative cognition hypothesis: a review of worry, prolonged stress-related physiological activation, and health. J Psychosom Res. 2006;60:113-24.

Several national clinical guidelines have proposed MBCT as a preventative and affordable treatment for relapse of major depressive disorder (such as the National Institute for Health and Care Excellence, 2009).2222. National Institute for Health and Care Excellence. Depression in adults: recognition and management. Clinical guideline [CG90]. London: NICE; 2009. There are theoretical considerations which suggest the MBCT is effective for reducing the rate of depression relapse and for primary maintenance of the effects of treatment for chronic depression that is more specifically used in TRD.1010. Segal ZV, Williams M, Teasdale J. Mindfulness-based cognitive therapy for depression. 2nd ed. New York: Guilford; 2018. Research has repeatedly shown that some patients prefer psychological treatments to taking antidepressants and it has also been shown that the combination of psychological therapies and antidepressants is more effective and persistent for treatment of psychological disorders.2323. Fletcher K, Foley F, Thomas N, Michalak E, Berk L, Berk M, et al. Web-based intervention to improve quality of life in late stage bipolar disorder (ORBIT): randomised controlled trial protocol. BMC Psychiatry. 2018;18:221. Considering that MBCT has been shown to be effective for preventing and treating depression, it seems likely to be effective for treating TRD too. Therefore, the main objective of this study was to determine the effectiveness of MBCT for depression symptoms in patients with TRD. The specific objectives of the present study were to determine the effectiveness of MBCT for mindfulness, self-compassion, and rumination in patients with TRD.

Methodology

Participants

The study design is experimental research (pre-test, post-test, and follow-up) with experimental and control groups. The study populations were all patients with TRD from Farabi Psychiatric Hospital. Means and standard deviations reported in previous studies were used to determine the required sample size.2424. Manicavasgar V, Parker G, Perich T. Mindfulness-based cognitive therapy vs cognitive behaviour therapy as a treatment for non-melancholic depression. J Affect Disord. 2011;130:138-44. Participants were selected with a purposive sampling method and randomly assigned to experimental or control groups. First, a list of all participants was prepared and then, drawing names out of a bowl, names were removed at random. The first name drawn was assigned to the experimental group and the second to the control group, and so on for all participants.

Procedure

The experimental group received MBCT and antidepressants, but the control group only received antidepressants. The MBCT sessions were held at Farabi Psychiatric Hospital and all of the patients were outpatients. The medication process was as follows: patients were initially treated with a dose of 60 mg citalopram for four to six weeks. Due to the lack of response during this period, they were given Sertraline at a maximum dose of 200 mg for four to six weeks. In addition to sertraline, bupropion was also prescribed. Anti-depressant medications were administered with appropriate dosages and durations, but no clinical response was observed, and so these patients were diagnosed as having treatment-resistant depression. The MBCT was conducted by a Master of Clinical Psychology (the corresponding author), who was trained in this field, and the supervisor (the lead author) monitored all of the treatment sessions.

The inclusion criterion was major depressive disorder diagnosed by psychiatrists and a clinical psychologist on the basis of structured clinical interviews. Additional criteria were lack of therapeutic response to adequate doses of two antidepressants for sufficient time (18 weeks); a moderate level of depression (score 17 or higher) according to the Beck Depression Inventory – Second Edition; minimum and maximum ages of 18 and 50 years old, respectively; the minimum educational level necessary to complete the questionnaire and; finally, patient’s consent to participate in the study and signature of written consent. The exclusion criteria were severe suicidal thoughts, psychiatric disorder, and acute phases of mental disorders (e.g. signs and symptoms of psychosis, bipolar disorder, comorbid anxiety disorders, panic disorder, posttraumatic stress disorder, seasonal depression, or depressive disorder due to substance abuse or medical condition) lack of treatment assignments, absence from more than two sessions, or patient’s unwillingness to continue taking part in the research ( Figure 1 ).

Figure 1
Study flowchart

Ethical considerations

The study was conducted in accordance with the Declaration of Helsinki and approved by the Ethics Committee at Kermanshah University of Medical Sciences (clinical trial code: IR.KUMS.REC.1396.586). Participants gave their consent to participation in the study by signing the consent form.

Statistical analysis

Data were coded, input to the Statistical Package for the Social Sciences (SPSS), version 18, and analyzed using descriptive statistics (mean and standard deviation) and inferential statistics (mixed analysis of variance for repeated measures). It should be noted that the data analysis process was blinded.

Instruments

Structured Clinical Interview for DSM-IV Disorders (SCID)

This is a semi-structured interview guide that is administered by a mental health professional who is familiar with mental health standards and criteria. The Persian version of the SCID was normalized by Sharifi V et al. The kappa coefficient for general agreement was 0.6 and overall weighted kappa equaled 0.52 for current diagnoses and 0.55 for lifetime diagnoses.2525. Sharifi V, Asadi SM, Mohammadi MR, Amini H, Kaviani H, Semnani Y, et al. Reliability and feasibility of the Persian Version of the Structured Diagnostic Interview for DSM-IV (SCID). Adv Cogn Sci. 2004;6(1):10-22.

Beck Depression Inventory – Second Edition (BDI-II)

The BDI is a 21-item self-report inventory that measures cognitive, emotional, physical, and vegetative symptoms of depression.2626. Beck AT, Steer RA, Brown GK. Manual for the Beck Depression Inventory-II. San Antonio: Psychological Corporation; 1996. The BDI-II is positively correlated with the Hamilton depression rating scale (r = 0.71), with good agreement, and it has also shown high one week test retest reliability (alpha coefficient = 0.91)

Hamilton Depression Rating Scale (HDRS)

The HDRS is the most widely used clinician-administered depression assessment scale. Recent studies have indicated an internal reliability coefficient of 0.83 for the 17-item HDRS and 0.88 for the 24-item HDRS.2323. Fletcher K, Foley F, Thomas N, Michalak E, Berk L, Berk M, et al. Web-based intervention to improve quality of life in late stage bipolar disorder (ORBIT): randomised controlled trial protocol. BMC Psychiatry. 2018;18:221. A study has recently been conducted to fully investigate the HDRS’ psychometric properties. In that article researchers reviewed 70 studies and found that the majority of HDRS items had a good reliability.2727. Bagby RM, Ryder AG, Schuller DR, Marshall MB. The Hamilton Depression Rating Scale: has the gold standard become a lead weight? Am J Psychiatry. 2004;161:2163-77. The reliability of the HDRS has been reported with a range from 0.65 to 0.91 for the general scale of depression severity.

Self-Compassion Scale – Short Form (SCS-SF)

The SCS-SF consists of 12 items and scores are based on how often an individual responds to feelings of inadequacy or suffering with self-kindness, self-judgment, mindfulness, isolation, common humanity, and over-identification. The short form has a high correlation (r = 97%) with the long scale and retest reliability has been reported to be 0.92%.2828. Raes F, Pommier E, Neff KD, Van Gucht D. Construction and factorial validation of a short form of the self-compassion scale. Clin Psychol Psychother. 2011;18:250-5. In Iranian samples, reliability and validity of this test have shown negative and meaningful correlations with perfectionism (0.33), negative affect (0.38), and external shame (0.21). Furthermore, the Cronbach’s alpha coefficient for the whole scale was estimated to be 0.86 and coefficients for the sub-scales of “self-judgment vs. self-kindness,” “common humanity vs. isolation” and “mindfulness vs. over-identification” were 0.68, 0.71, and 0.86 respectively.2929. Khanjani S, Foroughi AA, Sadghi K, Bahrainian SA. Psychometric properties of Iranian version of Self-Compassion Scale (Short Form). Pajoohandeh. 2016;21:282-89.

Ruminative Response Scale

The RRS consists of 22 items and measures individual responses to depressed mood. Reliability and validity were satisfactory for the scale’s two dimensions. Analysis of external validity indicated that RRS scores correlated with BDI, State-Trait Anxiety Inventory, and 36-Item Short Form Health Survey scores (SF-36).3030. Parola N, Zendjidjian XY, Alessandrini M, Baumstarck K, Loundou A, Fond G, et al. Psychometric properties of the Ruminative Response Scale-Short form in a clinical sample of patients with major depressive disorder. Patient Prefer Adherence. 2017;11:929-37. The psychometric properties of the Persian version have been reviewed and confirmed in several studies.3131. Manavipour D, Shahhosieni A. Investigation of psychometric properties of Rumination-Reflection Scale. Shefaye Khatam. 2016;4:7-16.

Southampton Mindfulness Questionnaire (SMQ)

The SMQ has 16 items and measures mindful awareness of distressing thoughts and images (responding mindfully to unpleasant thoughts and images). Cronbach’s alpha coefficient was reported as 0.89 in the normal population and 0.82 in a clinical group. Validation of the SMQ revealed a positive and significant correlation between it and the Mindful Attention Awareness Scale (MAAS).3232. Chadwick P, Hember M, Symes J, Peters E, Kuipers E, Dagnan D. Responding mindfully to unpleasant thoughts and images: reliability and validity of the Southampton Mindfulness Questionnaire (SMQ). Br J Clin Psychol. 2008;47:451-5. For the Persian version of the SMQ, confirmatory factor analysis identified three factors (comparative fit index [CFI] = 0.9; normed fit index [NFI] = 0.83; root mean square error of approximation [RMSEA] = 0.08). The results also showed that the SMQ had good convergence with self-compassion (0.59) and positive affect (0.40) and good divergent validity when tested against negative affect (-0.35), depression scale (-0.36), anxiety (-0.30), and stress (-0.50).3333. Azar G. Psychometric Properties of the Iranian Version of the Southampton Mindfulness Questionnaire [dissertation]. Kermanshah: Kermanshah University of Medical Sciences; 2018.

Treatment protocol

The instructions for treatment sessions are presented in Table 1 . They are based on the guideline for mindfulness-based cognitive therapy for depression.3232. Chadwick P, Hember M, Symes J, Peters E, Kuipers E, Dagnan D. Responding mindfully to unpleasant thoughts and images: reliability and validity of the Southampton Mindfulness Questionnaire (SMQ). Br J Clin Psychol. 2008;47:451-5.

Table 1
MBCT themes and content

Results

Comparisons of the demographic and clinical variables of experimental and control groups showed that there were no differences in sex, educational level, marital status, or age ( Table 2 ). Descriptive analysis of the variables was performed ( Table 3 ). The Kolmogorov-Smirnov test was used to test the distribution of data. The results indicated that data were normally distributed for all variables (p > 0.05). Additionally, the Levene test was used to assess equality of variances for variables in treatment and control groups. The results showed that there was no difference between the variances of the groups (p > 0.05).

Table 2
Comparison of demographic characteristics between the study groups

Table 3
Descriptive analysis of variables

Table 4 indicates that MBCT significantly changed the variables depression and self-compassion, though rumination and mindfulness. These meaningful changes were significant and persistent over time.

Table 4
Mixed-design analysis of variance with repeated measures of variables

Table 5 shows that in the experimental group meaningful changes were observed from pre-test to post-test (p < 0.01), while changes were stable and persistent in the follow-up period. In the control group, variables like depression (BDI) and ruminative response also decreased significantly, but the reductions were very low in comparison with the experimental group.

Table 5
Analysis of variables with Bonferroni pairwise comparisons

Discussion

The aim of the present study was to determine the effectiveness of MBCT for rumination, mindfulness, and self-compassion in patients with TRD. The results showed that MBCT reduced depression in the experimental group compared to the control group, which is consistent with the findings of Kingston et al.,3434. Kingston T, Dooley B, Bates A, Lawlor E, Malone K. Mindfulness-based cognitive therapy for residual depressive symptoms. J Psychol Psychother. 2007;80:193-203. Finucane and Mercer,3535. Finucane A, Mercer SW. An exploratory mixed methods study of the acceptability and effectiveness of mindfulness-based cognitive therapy for patients with active depression and anxiety in primary care. BMC Psychiatry. 2006;6:14. Papageorgiou and Wells,3636. Papageorgiou C, Wells A. Treatment of recurrent major depression with attention training. Cogn Behav Pract. 2000;7:407-13. Teasdale et al.,3737. Teasdale JD, Segal ZV, Williams JM, Ridgeway VA, Soulsby JM, Lau MA. Prevention of relapse/recurrence in major depression by mindfulness-based cognitive therapy. J Consult Clin Psychol. 2000;68:615-23. Kenny and Williams,3838. Kenny MA, Williams J. Treatment-resistant depressed patients show a good response to mindfulness-based cognitive therapy. Behav Res Ther. 2007;45:617-25. and Alberto Chiesa et al.3939. Chiesa A, Castagner V, Andrisano C, Serretti A, Mandelli L, Porcelli S, et al. Mindfulness-based cognitive therapy vs. psycho-education for patients with major depression who did not achieve remission following antidepressant treatment. Psychiatry Res. 2015;226:474-83. MBCT facilitates a detached or decentered view of one’s thoughts, emotions and bodily sensations. MBCT teaches depressed individuals to observe their thoughts and feelings nonjudgmentally and to view them as mental events that come and go, rather than as aspects of themselves. This attitude toward negative cognitions in depression prevents escalation of negative thoughts into rumination. MBCT helps depressed individuals learn to recognize their automatic cognitive-affective-behavioral patterns and relate to their experiences with curiosity, patience, and compassion.1111. Crane R. Mindfulness-based cognitive therapy: distinctive features. 2nd ed. London: Routledge; 2017.

Teasdale and Chaskalson articulate three mechanisms through which mindfulness training can help depressed people: 1) mindfulness training strengthening the ‘attentional muscles’ so that a natural transient sense of sadness is less likely to lead to depression; 2) mindfulness training cultivates attitudinal qualities of kindness, compassion, patience, nonjudgmentalness and openness to experiences, so that instead of avoiding negative emotions, patients learn to be open to these experiences; and finally, 3) mindfulness training changes the depressed patients’ beliefs about thoughts, body sensations, and feelings.4040. Teasdale JD, Chaskalson M. How does mindfulness transform suffering? I: the nature and origins of dukkha. Contemp Buddhism. 2011;12:89-102. , 4141. Teasdale JD, Chaskalson M. How does mindfulness transform suffering? II: the transformation of dukkha. Contemp Buddhism. 2011;12:103-24.

The results of the present study showed that MBCT reduced rumination in the experimental group compared to the control group. These findings are in line with those of Kingston et al.3434. Kingston T, Dooley B, Bates A, Lawlor E, Malone K. Mindfulness-based cognitive therapy for residual depressive symptoms. J Psychol Psychother. 2007;80:193-203. and Nolen-Hoeksema,4242. Nolen-Hoeksema S. Responses to depression and their effects on the duration of depressive episodes. J Abnorm Psychol. 1991;100:569-82. who have explained the role of rumination in vulnerability to depression. The decentering hypothesis can be taken in to consideration to explain the effectiveness of MBCT for rumination.4343. Teasdale JD, Segal Z, Williams JMG. How does cognitive therapy prevent depressive relapse and why should attentional control (mindfulness) training help? Behav Res Ther. 1995;33:25-39.

Decentering means the ability to focus on the present moment and achieve a state of being non-judgmental about thoughts and feelings and accepting them. Studies have shown that decentering can reduce the level of depressive rumination thought by teaching the patient to pay attention in a particular way.1212. Kabat-Zinn J. Mindfulness-based interventions in context: past, present, and future. Clin Psychol Sci Pract. 2003;10:144-56. Decentering includes distancing, separating, allowing, accepting, and dropping negative thoughts and ideas. Barnhofer et al. have noted that, by strengthening cognitive control mechanisms, meditation may lessen ruminative processes and thereby reduce depression. This theoretical background led us to hypothesize that MBCT could prove effective for reducing TRD.4444. Barnhofer T, Crane C, Hargus E, Amarasinghe M, Winder R, Williams JMG. Mindfulness-based cognitive therapy as a treatment for chronic depression: a preliminary study. Behav Res Ther. 2009;47:366-73.

The results of the present study revealed that MBCT increased mindfulness in the participants in the experimental group compared with those in the control group. Review and meta-analysis studies have been conducted to investigate the effect of mindfulness training on self-report mindfulness. The findings of those studies are in line with the present study.4545. Kuyken W, Watkins E, Holden E, White K, Taylor RS, Byford S, et al. How does mindfulness-based cognitive therapy work? Behav Res Ther. 2010;48:1105-12. , 4646. Birnie K, Speca M, Carlson LE. Exploring self-compassion and empathy in the context of mindfulness-based stress reduction (MBSR). Stress Health. 2010;26:359-71. Furthermore, the results of the present study showed that MBCT led to increased self-compassion. These findings are consistent with evidence that participation in mindfulness interventions such as the MBCT and mindfulness-based stress reduction increases self-compassion.4545. Kuyken W, Watkins E, Holden E, White K, Taylor RS, Byford S, et al. How does mindfulness-based cognitive therapy work? Behav Res Ther. 2010;48:1105-12.

46. Birnie K, Speca M, Carlson LE. Exploring self-compassion and empathy in the context of mindfulness-based stress reduction (MBSR). Stress Health. 2010;26:359-71.
- 4747. Rimes KA, Wingrove J. Pilot study of mindfulness-based cognitive therapy for trainee clinical psychologists. Behav Cogn Psychother. 2011;39:235-41. Recently, it has been hypothesized that increased self-compassion leads to increased individual well-being.4848. Hölzel BK, Lazar SW, Gard T, Schuman-Olivier Z, Vago DR, Ott U. How does mindfulness meditation work? Proposing mechanisms of action from a conceptual and neural perspective. Perspect Psychol Sci. 2011;6:537-59. , 4949. Baer RA. Self-compassion as a mechanism of change in mindfulness-and acceptance-based treatments. Assessing mindfulness and acceptance processes in clients: Physiother Theory Pract. 2010:135-53. In fact, mindfulness increases the ability to experience self-compassion and accept personal mistakes, negative thoughts, and emotions as part of the human experience. If a person is aware of the experience of suffering and accepts it without judgment, sufficient mental space will be allocated to experiencing self-compassion and a desire will be formed to alleviate suffering from himself and others.5050. Neff KD, Dahm KA. Self-compassion: What it is, what it does, and how it relates to mindfulness. In: Handbook of mindfulness and self-regulation. New York: Springer; 2015. p. 121-37. Several theoretical models have emphasized the importance of self-compassion in development of well-being, in reduction of anxiety and depression, and in resilience to stress.5151. Hofmann SG, Grossman P, Hinton DE. Loving-kindness and compassion meditation: potential for psychological interventions. Clin Psychol Rev. 2011;31:1126-32.

52. Gilbert P. An introduction to compassion focused therapy in cognitive behavior therapy. Int J Cogn Ther. 2010;3:97-112.
- 5353. Feldman C, Kuyken W. Compassion in the landscape of suffering. Contemp Buddhism. 2011;12:143-55.

Limitations

The limitations of this study were a small sample size and the follow-up time in the current study was limited to one month, which does not allow for informed conclusions about possible longer-term effects of MBCT and their comparison.

Conclusion

The results showed that MBCT leads to a significant reduction in depressive rumination and increased self-compassion and mindfulness in the treatment group (MBCT combined with antidepressants). This treatment can be considered a promising intervention for improving depression in patients with TRD.

Suggestions

Since MBCT was effective for decreasing depression and rumination and for increasing self-compassion and mindfulness in patients with TRD, it is suggested that clinicians use MBCT as an effective treatment for TDR. It is also recommended that the mediators of this treatment be investigated in future studies. Furthermore, it is suggested that a larger sample size be used in future studies.

Acknowledgments

The authors gratefully acknowledge the Research Council of Kermanshah University of Medical Sciences (Grant Number: 96306) for financial support.

References

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    » https://www.who.int/news-room/fact-sheets/detail/depression
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    Ledari RB, Masjedi A, Bakhtyari M, Zarghami M, Nouri R, Hosseini H. A comparison between the effectiveness of acceptance and commitment treatment and behavioral activation treatment for depression on symptoms severity and rumination among patients with treatment-resistant depression. Iran J Psychiatry Behav Sci. 2018;12:e10742.
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Publication Dates

  • Publication in this collection
    17 July 2020
  • Date of issue
    Apr-Jun 2020

History

  • Received
    11 Mar 2019
  • Accepted
    21 Oct 2019
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